Narrow Nose

A narrow nose is less commonly a presenting concern than a wide nose, but occurs in two distinct clinical contexts — as a primary characteristic of the nose, or as a complication of previous rhinoplasty in which the nose was narrowed excessively. In both cases, narrowness may affect both the appearance and the nasal airway, as a narrow external nose is frequently associated with a compromised internal nasal valve.

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Assessment of Nasal Width

The width of the nose is assessed at three levels — the bony upper third, the cartilaginous middle third, and the lower third including the tip and alar base. Each may be narrow independently or in combination.

Brow-tip aesthetic line — should be smooth and uninterrupted on each side

Facial vertical fifths — nasal width in proportion to facial width

A useful clinical reference is the brow-tip aesthetic line — the smooth, gently curved line that should extend from the medial brow down to the nasal tip on each side. Narrowing of the middle or lower third disrupts this line and is clearly visible on frontal view. Nasal width can also be assessed in proportion to facial width — the nasal base is generally approximately one fifth of the total facial width, though this varies considerably between individuals and ethnic backgrounds.

Causes

• Primary narrow middle third — the upper lateral cartilages are naturally positioned close to the septum, narrowing the internal nasal valve and producing a narrow middle third appearance
• Post-rhinoplasty — excessive osteotomies that have moved the nasal bones too far inward, or a cephalic trim that has weakened and collapsed the lateral crura, can produce a nose that is narrower than intended
• Scarring and contracture — scar tissue following surgery can progressively narrow the nose over time as it contracts

Surgical Treatment

The most common site of narrowing is the middle third, which can be effectively widened using spreader grafts — cartilage grafts placed between the nasal septum and upper lateral cartilages that push the lateral cartilages outward, widening both the external nasal appearance and the internal nasal valve simultaneously.

Spreader grafts — the primary technique for widening a narrow middle third

For narrowness of the bony upper third resulting from over-aggressive osteotomies, the nasal bones may need to be re-fractured and repositioned outward — a technically demanding revision procedure. Narrowness of the lower third and alar region is addressed through lateral crural strut grafts or alar batten grafts.

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